Evolution of the Adenoidectomy in the Endoscopic Era

During the last 20 years, we have observed an increasing recognition of the high prevalence of sleep-disordered breathing (SDB) in children. Adenotonsillar enlargement, leading to a partial or a complete obstruction of the nasopharynx (or epipharynx, or rhinopharynx) and/or of the oropharynx, accounts for the vast majority of cases. Consequently, the number of adenoidectomies performed in children for SDB has increased significantly. An adenoidectomy can be performed as an isolated procedure or as part of an adenotonsillectomy operation. As a matter of fact, adenoidectomy with or without tonsillectomy is one of the most common surgical procedures performed by Otolaryngologists in the paediatric population. Historically, tonsil and adenoid surgery increasingly began to be carried out together in the early 20th century, as the popular “focus on infection” theory attributed various systemic disorders to diseased tonsils and adenoids; thus, tonsillectomy plus adenoidectomy were recommended as a standard treatment for several different conditions as anorexia, mental retardation and enuresis, or simply as a general measure to promote good health (Hays, 1924; Kaiser, 1932). In certain communities the surgical procedure was performed widely in the entire population of scholars in public school buildings (Baker, 1953). Over the years, things have changed, and precise indications were proposed for tonsillectomy and adenoidectomy. Adenoid hypertrophy can lead to obstructive sleep apnea, otitis media with effusion, recurrent otitis media and nasal obstruction, and nowadays these remain the most common indications for adenoidectomy. Techniques and instruments have considerably evolved from the first techniques described by Cornelius Celsus in the first century A.D. (Thornval, 1969) and Paul of Aegina in 625 A.D. (Paul of Aegina, 1847) to the later contributions of surgeons such as Wilhelm Meyer of Copenhagen and Samuel J. Crowe in the last centuries (Curtin, 1987; Meyer, 1870; Wiatrak & Wooley, 2005; Younis & Lazar, 2002). Pioneers of tonsillectomy and adenoidectomy have developed novel techniques and instruments in order to increase the speed of the procedure, especially in the pre-anesthesia era, and to decrease the intra-operative complications and postoperative morbidity. The classic surgical technique performed with an adenoid curette or an adenotome has recently evolved by the introduction of the endoscopic sinus surgery (ESS)